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Clinical practice benchmarking is a new quality improvement benchmarking approach that involves structured learning from others in order to improve, accepting the subjective nature of health care. Evaluative research of clinical practice benchmarking requires mixed methods, quantitative and qualitative. This challenges the current reliance upon quantitative consideration of the effectiveness of quality improvement approaches. A worked quantitative example is provided and demonstrates that descriptive statistics support comparison activity only. It rejects the value of inferential statistics, since benchmark scores relate to subjective statements. Therefore, inter-rater reliability is poor and it is not possible to directly attribute any change in clinical practice benchmark scores to actual changes in practice. Following the quantitative analysis, a qualitative research study was undertaken from an interpretative perspective to evaluate the effectiveness of clinical practice benchmarking as a quality improvement approach. Particular emphasis was given to exploring the organisational factors that support its effectiveness. Data were gathered through semi-standardised interviews of nursing leaders of local paediatric benchmarking activity and frontline nurses, with rigour ensured through reflexivity and a critical approach to the analysis. The main empirical contribution of this work provided new knowledge about nurses' understanding of clinical practice benchmarking. They defined it as using all evidence to agree best practice, focusing upon collaboration to support sharing, rather than competition. The findings identified the organisational factors that ensured the effectiveness of clinical practice benchmarking. The main enablers were motivation of those involved and supportive leadership, underpinned by an organisation that promotes learning and innovation. This research provides compelling evidence that clinical practice benchmarking is an effective approach to quality improvement in health care. However, it requires acceptance of the importance of the subjective nature of health care and the necessity for qualitative approaches to evaluation. Methodological insights from this study also inform future evaluative research.

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Introduction and Rationale: Concussions account for the majority of traumatic brain injuries in children. Currently there more than 500,000 pediatric concussions per year and that number is likely low due to under-reporting (Rose, Weber, Collen,& Heyer, 2015). Most symptoms of concussion are easily recognized to the trained pediatric primary care provider. Yet, symptom management and recommendations for rest, exercise, specialty care referral, and return to normal activities can be challenging for many providers, due to the lack of evidence and lack of formal recommendations by any organization (Rose et al., 2015; Silverberg & Iverson, 2013). Purpose and Objective: The main purpose of this Doctor of Nursing Practice (DNP) project is to develop evidence-based clinical practice guidelines (CPG) for pediatric primary care providers. The objective is to provide a CPG that offers clinical guidance when managing pediatric concussion patients in the primary care setting. This CPG will also provide clarity for pediatric primary care providers (PCP) when determining what options are available in treatment for pediatric concussions. Methods: The working framework of this project was The Appraisal of Guidelines for Research & Evaluation II (AGREE II). The American Academy of Pediatrics (AAP) procedure for reporting clinical guidelines, in the form of key action statements, was used as the model for development of the CPG. Results: The CPG was appraised using the AGREE II instrument, which provides valid and reliable scores and data used in the evaluation of CPG's. Six domains were evaluated, and the CPG yielded scores above 80% for all categories. The overall standard deviation was 0, which indicts a very low level of discrepancy between users of the instrument. Conclusion: This DNP project addresses an evidence and primary care practice gap. With a large number of pediatric concussions, a consistent management approach will ensure a safe and therapeutic recovery. A CPG was developed and evaluated using the AGREE II instrument. The CPG was found to meet the standards for general recommended use in pediatric primary care.

Quelle est la force juridique des RBP en matière sanitaire, en plein contentieux comme en recours pour excès de pouvoir? Quelles sont les différences d'approche entre la France et les Etats-Unis? / What's the legal strength of CPGs in healthcare, in France and in the United States?The Institute of Medicine has defined as soon as 1992 Clinical Practice Guidelines as "systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances." As they derive from various public and private bodies, and from the consensus of experts, CPGs are considered as consensus statements representing the prevailing standard of care in the medical profession. Clinicians and judges use clinical practice guidelines in their everyday life to appreciate individual situations and reach the best solutions for patients and plaintiffs: CPGs help improve their decision-making. But the legal strength of these tools is not totally consensual. In France, CPGs are seen as evidence of the standard of care expected from physicians. In theUnited States, where CPGs appeared some years earlier, they have been subject to questions, denounced as symptoms of a “cookbook medicine” and object of experiments by various States and insurance companies – not to mention lobbies. Their legal weight seems all the same better established in the U.S. than in France, although rulings in 2011 and 2016 by the french Conseil d’Etat have given them a more central role and a more recognized legal position in France.

The purpose of this study is to examine the role of spirituality in the social work practice and social worker’s perspective on it. This project focuses on spirituality in social work and the role that it plays in a social workers practice. The data collected for this research project consists of qualitative data in which the researcher conducted one-on-one interviews of eight different clinical professionals in the social work field. The study employed a purposive sampling by recruiting LCSW’s, MSW’s, ASW’s, and other clinical professionals in the Northern California area. The average years of experience amongst the participants was 19.375 years. Each participant has a broad range of experience from individual clinical one-on-one counseling, working with groups, and supervision.

Childhood obesity is a national problem in the United States and has known implications as a potential cause of chronic illnesses as the child transitions into adulthood. A primary care clinic in the southwestern United States had a high percentage of obese Hispanic children within its population; therefore, the nurses and the pediatrician needed an evidence-based clinical practice guideline (CPG) to manage Hispanic children with a body mass index greater than the 95th percentile for their age. The purpose of the project was to develop a culturally competent CPG to manage childhood obesity in this primary care practice. The social cognitive theory provided the framework to develop the CPG. The final project resulted in an evidence-based CPG that was validated by an expert physician panel. The implication of this project is that nurses and providers can provide culturally competent education to the parent and child to reduce obesity among the pediatric Hispanic population. This project may create positive social change by modifying unhealthy cultural practices and behaviors, preventing chronic diseases, and reducing health care costs for the children within the selected practice.

This workplace study examined the every day ethical dilemmas of a multidisciplinary team in one acute psychiatric setting and the social factors affecting their moral domain of practice. The research design was a case study involving both qualitative and quantitative data. The context that shaped the team's process of ethical dilemma identification was conceptualised for the purpose of this research within a systems theory framework of interrelated factors at a societal, organisational and clinical level with ethics theory pervading the entire scene. The findings indicated that dilemmas arose in situations concerning patient care, team strain, and limited resources with the most common dilemma across disciplines arising from lack of community resources. Further findings suggested that clinicians were aware of various forces shaping practice but these ideas were not well connected conceptually. Staff felt wary of identifying ethical dilemmas because they were unsure of the process and sensed a reticence in the unit's social processes around negotiation and problem solving. Important social factors that were perceived to affect their abilities around ethical dilemma identification included rational economics, professional socialisation, medical-legal monopoly with a concomitant use of the ethic of justice, and managerial strategies. The concept of transference and countertransference issues within the staffing group was explored. These results are useful for the team to understand the nature of their own particular dilemmas and what factors constrain and enhance their abilities to identify dilemmas. Other health care settings may find that replication of the research results in a similar way may raise awareness of their moral situation. Generalisability at a theoretical level contributes to the current research agenda in applied ethics about the effect of context in the ethical domain of clinical practice.

Healthcare professions are known to be inherently moral. They confront on a daily basis essential ethical problems. However, my experience as a nurse shows a different reality. In practice healthcare professionals often have difficulty to even identify the ethical problem before attempting to resolve the situation. In a plethora of literature moral case deliberation (MCD) is discussed as method to address these limitations of healthcare professionals. In general MCD can be defined as a discussion with the different parties involved about the ethical issues of a real case in clinical practice. In order to achieve a more comprehensive understanding of MCD I identified MCD's main features and reviewed two methods (Clinical pragmatism and the Hermeneutic method) as examples. This review  unfolded certain assumed normative ideas more or less common in many models of MCD. However it is unclear how to understand these normative ideas and as to whether they should indeed guide MCD. Throughout the thesis I concentrate on some of these assumptions. I focused on the three, which I considered the most relevant for the implementation of MCD into clinical practice: 1) the involvement of everyone concerned the case, 2) consensus as an ideal within MCD and 3) MCD improves decision making. The aim of the thesis was to reflect on how these assumptions could be reasonably understood and to outline remaining ambiguities and points for critique in their application within MCD. Hence I am not arguing whether MCD should be part of clinical practice or not, I am critically reviewing the process of MCD within clinical practice. Finally, in the thesis it is illustrated that for each assumption various plausible explanations are possible, which all might have a role in practice. The usefulness of MCD might depend on what relevance these explanations are given in practice.